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It was reported to siemens that an incident occurred while operating a somatom definition as ct system.According to the customer the ct examination was performed due to hematuria.During a whole-body scan, after the patient had already been positioned in the gantry, the operator in the control room pressed the movement button on the control box in order to move the patient handling system (phs).While the phs with the patient was moving back from the tabletop, the patient¿s elbow dangled off the tabletop and was fractured.The injury was discovered only after completion of the table movement as the patient had suffered a stroke and was unable to speak.
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According to available information no acute stroke patient was involved in the reported event.The examination was not performed to treat a stroke but was scheduled because of hematuria.The patient required surgical treatment for the fracture.At the time of reporting, the patient had already left the hospital.However, no negative health consequences caused by the system itself were reported.Siemens healthineers completed a safety and technical assessment.The investigation confirmed that the system functioned as specified and no malfunction or design issue was identified.The root cause of the event was attributed to customer related issue, as the patient¿s body parts were not fully positioned on the patient table during table movement.The following warnings are clearly stated in the instructions for use: somatom definition as ¿ instructions for use print no.C2 029.620.16.03.02 page 172ff: caution ¿ lowering the patient table! body parts can get caught.Make sure that the patient¿s body parts are above the patient table.Make sure that neither body parts of anybody nor any objects are below the patient table.Page 171: stop keys with the stop keys, table movements can be interrupted in an emergency, and radiation can be switched off.Based on the available information, no systematic, general, or design issue was identified.
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